Practice Essentials

Epiglottitis is an acute inflammation in the supraglottic region of the oropharynx with inflammation of the epiglottis, vallecula, arytenoids, and aryepiglottic folds (see the image below).
[1] Anecdotally, George Washington probably died of epiglottitis in 1799.

Workup

Airway management is the most urgent consideration, and patients should first be assessed for level of distress before any other workup. Adults generally present in a less acute fashion than children.
[2] Ensure that an anesthesiologist and an otolaryngologist are available.

Radiographic evaluation for suspected epiglottitis is being replaced by direct visualization of the epiglottis using nasopharyngoscopy/laryngoscopy as the preferred method of diagnosis.

Signs and symptoms associated with a need for intubation include respiratory distress, airway compromise on examination, stridor, inability to swallow, drooling, sitting erect, and deterioration within 8-12 hours. Enlarged epiglottis (thumb sign) on radiographs is associated with airway obstruction. When in doubt, securing the airway is likely the safest approach.

Blood cultures may be taken, particularly if the patient is systemically unwell. The cultures are positive in approximately 25% of adult cases. If the airway is secure, epiglottic cultures may be performed.

Management

Unstable patients

A patient in extremis requires immediate airway management. Patients may deteriorate precipitously, and airway equipment, including that for cricothyrotomy, should be present at the patient's bedside. Needle-jet insufflation (also known as percutaneous transtracheal jet ventilation [PTJV]) may also be considered to ventilate the patient temporarily.
[3] Intubation or immediate formal tracheostomy or cricothyrotomy may be performed in the operating room if the case is less severe.

In cases of initial failure to intubate by direct laryngoscopy, PTJV may facilitate success in subsequent attempts at tracheal intubation by direct laryngoscopy.

Stable patients

Patients without signs of airway compromise, respiratory difficulty, stridor, or drooling, and who have only mild swelling on laryngoscopy, may be managed without immediate airway intervention by close monitoring in the intensive care unit (ICU). Because of the rapidity with which airway obstruction can occur in these patients, repeat serial evaluations of airway patency and maintenance of a low clinical threshold for airway placement are indicated.

Although community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is becoming an increasingly important pathogen; as of 2007, MRSA rarely causes epiglottitis.
[4]

Noninfectious causes of epiglottitis are not uncommon and produce similar disease. Etiologies include thermal causes (including those associated with crack cocaine smoking and marijuana smoking, as well as throat burns affecting the epiglottis of bottle-fed infants), caustic insults (eg, automatic dishwasher soap ingestion), and foreign body ingestion (eg, following ingestion and expulsion of a bottle cap
[5] ). Epiglottitis may also occur as a reaction to head and neck chemotherapy.
[6]

A retrospective study by Suzuki et al indicated that risk factors for severe epiglottitis in adults includes older age, a body mass index of over 25.0 kg/m2, and the presence of diabetes mellitus, epiglottic cyst, or pneumonia, at admission. The study included 6072 patients with epiglottitis, including 9.4% with a severe form of the condition.
[7]

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Epidemiology

Epiglottitis is classically associated with Haemophilus influenzae type b (Hib) infection and children. However, as has been observed with other infections caused by this agent, the overall incidence of epiglottitis has dramatically dropped in young children globally, as well as older age groups and adults, upon general adoption of Hib vaccine; furthermore, the most typical patient affected by epiglottitis in industrialized areas with vaccination programs is now an urban male in his mid 40s. Groups with higher morbidity include infants younger than 1 year and adults older than 85 years.
[8, 9]

In United States, epiglottitis is an uncommon disease with an incidence in adults of about 1 case per 100,000 per year. Adult epiglottitis is most frequently a disease of men (male-to-female ratio, approximately 3:1), occurring during the fifth decade of life (average age, about 45 y). The ratio of incidence in children to adults was 2.6:1 in 1980 and dropped to 0.4:1 in 1993, a dramatic decrease in occurrence since the introduction of the Haemophilus influenzae type b vaccine (Hib). However, keep in mind that vaccine failures are possible.

Globally, epiglottitis is generally more common in nations that do not immunize against H influenzae type b. For example, in Sweden from 1987 to 1989, the incidence was 14.7 per 100,000 people per year in children aged 0-4 years and 3.2 per 100,000 people per year overall.
[10] A large-scale Hib vaccination program in 1992-1993 resulted in a substantial decrease in Swedish cases of acute epiglottitis.

A retrospective review of a Danish population demonstrated a mean national incidence of epiglottitis in children of 4.9 cases per 100,000 per year in the decade before Hib vaccination. From 1996 to 2005, with the introduction of widespread Hib vaccination, an incidence of only 0.02 cases of epiglottitis per 100,000 per year was seen. During this period, the incidence of acute epiglottitis in adults remained constant, at 1.9 cases per 100,000 per year.
[11]

A retrospective review from the tropical country of Singapore over 8 years, ending in 1999, demonstrated 32 cases of acute epiglottitis, only 1 of which occurred in a child.
[12] During this time, Hib immunization was not routine, so Hib immunization cannot be used to explain the increased adult epiglottitis prevalence found in this study.

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Prognosis

The prognosis in adults with acute epiglottitis is good with appropriate and timely treatment. Most patients can be extubated within several days. However, unrecognized epiglottitis may rapidly lead to airway compromise and resultant death.

In spite of acute epiglottitis generally having a good prognosis, the risk of death for persons is high due to sudden airway obstruction and difficulty intubating patients with extensive swelling of supraglottic structures. Reported cases do include sudden fatal cardiorespiratory arrest occurring in patients without previous evidence of respiratory obstruction while in an intensive care unit (ICU) setting, emphasizing the importance of providing close monitoring and adequate airway protection in these patients. The adult mortality rate is around 7%.

A retrospective study by Bellis et al of 11 adult cases of fatal acute epiglottitis reported the chief postmortem observations to include hyperemia and edema of the epiglottis and aryepiglottic folds.
[13]

A retrospective study by Shapira Galitz et al indicated that in adult acute epiglottitis, patients with an aggressive disease course are more likely to be male, have dyspnea and stridor, present with edema of the epiglottis and aryepiglottic fold, and have an elevated C-reactive protein level, hyperglycemia, and a history of recurrent episodes.
[14]

Tables

Contributor Information and Disclosures

Author

Sandra G Gompf, MD, FACP, FIDSA Associate Professor of Infectious Diseases and International Medicine, University of South Florida College of Medicine; Chief, Infectious Diseases Section, Director, Occupational Health and Infection Control Programs, James A Haley Veterans Hospital

Debra Slapper, MD Physician, Southwest Washington Free Clinic System-Urgent Care; Former FEMA Physician and Military Contractor; Former Associate Professor, University of Miami, Leonard M Miller School of Medicine and University of South Florida Morsani College of Medicine